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. j l r o a carg reevi <br /> _�OR OFFICE USE: y� FOR OFFICE USE: <br /> F - - APPLICATION FOR SANITATION PERMIT <br /> ------- ------------------------------------ G� C, <br /> ------- -- - (Complete in Tr�olicate� Permit No.____'7 _7 _ _____ <br /> Date Issued__Y_le._77 <br /> --------------------------------------------------------- This Permit Expires t Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No..549 and existing Rule$ and Regulations: <br /> JOB ADDRESS/LOCATION. SAN_ �vll--------- -d T----- $---CENSUS TRACT ----- --------------- --------- <br /> Owner's Name-------- ------ i9 ----------- 'A�' s-- -------------------------------- -----------------------------------Phone-------- ----------- -- <br /> Address------------•1�f-(s-ar------ L `9���`l �Y ��1� --------------------- -------City-1----------------------- ----ZiP---i--------------- ---------- <br /> Contractor's Name__ A_Afrhovirv---f--S /Y.--------------------------------License #-__ 6 :.0 -------Phone. <br /> !1 <br /> Installation will serve: Residence$f Apartment House[] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------------------- <br /> Number of living units:-----['--------Number of bedrooms-. __....Garbage Grinder_.._____--Lot Size__________ ___________________._-------._ <br /> Water Supply: Public System and name---------91 S' �_Ct - t-_-._._ _____________Private <br /> - - <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 'Clay ❑ Peat❑ Sandy Loam❑- Clay Loam ® rd <br /> Hardpan ❑ Adobe ❑ Fill Material___.______If yes, type-------------------------------- d <br /> - a <br /> (Plot plan, showing size of lot, location of system in relation to w ;buildirigs,etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted iTpublic sewer is available witfiin 200 feet;) <br /> PACKAGE TREATMENT i[ ] SEPTIC TANK ['j Size:-----------------------------------------------------Liquid Depth.-___.-.-___._-.__---- <br /> !Capacity---«fid-------Type__--'9PO4�"47-Material _CO A�G----------No. Compartments--- -.Z------------ --- -------- <br /> Distance-.ta-aearest;Well_____ _______ ---------__________Foundation ___l0---------------Prop. Line.__-/4F7----------------- <br /> LEACHING <br /> .._ ____.---.LEACHING LINE [ ] No. of Lines------------- of each line.��-'rRp__,_____.Total Length.'3ao__s$__FT________--- <br /> F•`4 Te,r' A.3fel 'D' Box.... ------Type Miter Material._g�'�K-----Depth Filter Material_._- dim <br /> Distance to nearest:'Well------------------------ _(Foundation___�;J�---- __--___Property Line--.-.t'! ----------------------- <br /> SEEPAGE <br /> .-. --- <br /> SEEPAGE PIT [ ) Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth- -------- -- ---- -- ---------Ro2# Size------------------------------------------------ <br /> Distance to nearest: Well_;-----.__._._________ .___.Foundation-------------------------- Line_'_-_- ____-______ _--___. <br /> REPAIR/ADDITIdN (Prev. Sanitation Permit#_______________________.______.____.._____--.---.Date---------------------------------------------- <br /> Septic <br /> __________._______._-.- ____._-- -____Septic Tank (Specify Requirements)--------------------------------------------------------------------------------------------------------------------------- ------------- -------- <br /> DisposalField (Specify Requirements)______________________ ____--------------------------------------------------------------------------------------------------------------- <br /> -----------•------------------------------------------------------------ <br /> -------------------------------- -- - ----- - - -- - -------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hime owner or licensed agent <br /> signature certifies the following: <br /> "I certify that in the performance of the work for w1iich..this--permit is issued, l shall not emplay.a4y person in :such manner a <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-.-- ,E. �' T ®/Y �f® -------------------------------------Owner 4­ <br /> By--------- - ----Title----- ----------------------------------------------------------------- <br /> (If t han owner) <br /> DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ----- -- ---- - - ---- -- ----- -------DAT .- <br /> DIVISION OF LAND NUMBER.-- -- - -------------------------- ---DATE - <br /> ADDITIONAL COMMENTS i�----------- --- ---------------------------------- ------- ----- <br /> ----------------------------------------------------------------------`-------------------`------•--------------------------------------------------------------------------_-•------------------------ <br /> ---------------------- --------- - ------------ - <br /> ------------------------------------- -------- ----- ------------------------------ <br /> Final Inspection bY: - -------Date <br /> d = ,� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 ane <br />